Referral Information

Referral Source Name

Billing #

Professional Designation

Email

Agency Name and Office Mailing Address

Phone

Fax

We Ask Because We Care

Mental Health and Addictions providers in Brampton, Bramalea, Bolton/Caledon, Dufferin County, North Etobicoke, Malton, and west Woodbridge (the Central West LHIN) are collecting social information from individuals seeking service to find out who we serve and what are the unique needs amongst these individuals. We will also use this information to understand people's experiences and outcomes.

1. Do I have to answer all the questions? No. The questions are voluntary and you can choose "prefer not to answer" to any or all questions. This will not affect your care.

2. Who will see this information? This information will be visible only to your health-care team and protected like all your other health information. If used in research, this information will be combined with data from all other individuals and no one will be able to identify any of the individuals seeking service.

What language would you feel most comfortable speaking in with your health care provider? Choose ONE.

Other language

Which of the following best describes your racial or ethnic group? Choose ONE